Article Detail - JD DME

Original Effective Date: 01/01/2001
Revision Effective Date: 11/01/2013

In some areas of the country, Medicare beneficiaries have the option of enrolling in a Medicare health maintenance organization (HMO). The benefit to the enrollee is that Medicare HMOs may offer more services or have more lenient coverage policies than traditional fee-for-service (FFS) Medicare. In addition, beneficiaries have the option of moving into and out of the HMO and fee-for-service programs. The movement of beneficiaries, whether voluntarily or involuntarily (i.e., disenrollment of the HMO or Managed Care plan from participation in the Medicare program), has implications for coverage under FFS Medicare rules.

A beneficiary who was previously enrolled in a Medicare HMO/Managed Care program, returning to traditional FFS Medicare, is subject to the same benefits, rules, requirements and coverage criteria as a beneficiary who has always been enrolled in FFS Medicare. When a beneficiary returns to FFS Medicare it is as though he or she has become eligible for Medicare for the first time. Therefore, if a beneficiary received any items or services from their HMO or Managed Care plan, they may only continue to receive such items and services if they would be entitled to them under FFS Medicare coverage criteria and documentation requirements.

For example, a beneficiary who has obtained a manual wheelchair through an HMO/Managed Care plan must under traditional FFS Medicare obtain a CMN and meet FFS Medicare criteria for a wheelchair before a new capped rental period would begin.

There is an exception to this rule if a beneficiary was previously enrolled in FFS and received a capped rental item, then enrolled in an HMO, stayed with the HMO for 60 or fewer days, then returned to FFS. Enrollment in an HMO for 60 or more days would be considered an end to medical necessity.

Suppliers should maintain open communication with beneficiaries and determine, prior to delivery of an item or continued rental, whether there has been a change in enrollment from a Medicare HMO to FFS Medicare.